NIH Stroke Scale Questions and Answers 2023

NIH Stroke Scale Questions and Answers 2023 1A - Level of consciousness (stimulate, rub, pinch) 0 - Alert; keenly responsive 1 - not alert, Arouses to minor stimulation 2 - Requires repeated stimulation to arouse 3 - reflex movements only or totally unresponsive; Postures or unresponsive( use painful/noxious stimulus) 1B - Ask month and age 0 - Both questions right 1 - One question right 1 - Dysarthric, intubated, trauma, or language barrier 2 - Aphasic 1C - "Blink eyes" and "Squeeze hands" (ask pt to close eye, then open, L-hand make fist) 0 - Performs both tasks 1 - Performs one task 2 - Performs neither task 2 - Best Gaze (Test horizontal extraocular muscles) (position of eyes @ rest, spontaneous moving L or R, follow your finger; tract finger side to side) 0 - Normal; no visual loss 1 - Partial gaze palsy: can be overcome; partial hemianopia. Partial gaze palsy: corrects with oculocephalic maneuver 2 - complete hemianopia. Forced gaze palsy: can not be overcome occulocephalic maneuver 3- bilateral hemianopia (blind including cortical blindness) 3 - Test visual fields (one hand cover eye, tell pt to look at your eyes/nose and does pt see which hand is moving then do with other eye) 0 - No visual loss 1 - Partial hemianopia 2 - Complete hemianopia 3 - Patient is bilaterally blind 3 - Bilateral hemianopia 4 - Test facial palsy (use grimace if obtunded) (show me your teeth/gum, lift eyebrows, close eyes as hard as you can)(symmetry of grimace is basis of scoring) 0 - Normal symmetry 1 - Minor paralysis (flat nasolabial fold, asymmetric smile) 2 - Partial paralysis (lower face) 3 - Unilateral complete paralysis (upper/lower face) 3 - Bilateral complete paralysis 5A - Test left arm motor drift (extend arm 90 if sitting or 45 if supine)(start counting visually w/fingers when release arm) (start with non paretic arm) 0 - No drift for 10 seconds 1 - Drift, but doesn't hit bed 2 - Drift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 5B - Test right arm motor drift 0 - No drift for 10 seconds 1 - Drift, but doesn't hit bed 2 - Drift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 6A - Test left leg motor drift (suspend leg at 30 degrees) 0 - No drift for 5 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 6B - Test right leg motor drift 0 - No drift for 5 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 7 - Test limb ataxia (Finger-to your finger then back to nose, heel-shin up and down opposite leg) 0 - No ataxia 1 - Ataxia in 1 limb 2 - Ataxia in 2 limbs 0 - Doesn't understand, paralyzed, amputation 8 - Sensory (pinprick, safety or seamstress pin) (asymmetry in two sides(same or sharper); is there is difference. In obtunded look for grimace) 0 - Normal 1 - Mild-moderate loss: less sharp/more dull 1 - Mild-moderate loss: can sense being touched 2 - Complete loss: cannot sense being touched 2 - No response and quadriplegic 2 - Coma, unresponsive 9 - language (aphasia) (Describe the scene, name words, read the sentences) 0 - Normal; no aphasia 1 - Mild-moderate aphasia: some obvious changes without significant limitation 2 - Severe aphasia: fragmentary expression, interference needed, cannot identify materials 3 - Mute/global aphasia: no usable speech/auditory comprehension 3 - Coma, unresponsive 10 Test dysarthria (read words: Mama, Tip-top, Fifty-fifty, Thanks, Huckleberry, Baseball player) 0 - Normal; no dysarthria 1 - Mild-moderate dysarthria: slurring but can be understood 2 - Severe dysarthria: unintelligible slurring or out of proportion to dysphasia 3 - Mute/anarthric 0 - Intubated/unable to test 11 - Test extinction/inattention (presence of neglect of sensation on L or R or both, ask pt to close eye, ask pt which side is being touch. Wiggle finger on either side of patient R or L or both) 0 - No abnormality 1 - Visual/tactile/auditory/spatial/personal inattention 1 - Extinction to bilateral simultaneous stimulation 2 - Profound hemi-inattention (does not recognize own hand) 2 - Extinction to > 1 modality What NIHSS measures measures severity of symptoms of stroke NIHSS areas of assessment Level of consciousness Vision Extraoccular movements Facial Palsy Limb strength Ataxia Sensation Speech and language